• Travel Questionnaire

  • Please complete and submit the following travel form for the practice nurse to review. You will then need to call the practice after 5 days to book an appointment.

  • Personal Details
  • Sex*
  • Date Of Birth*
     / /

  • Trip Dates
  • Departure Date*
     / /
  • Return Date*
     / /

  • Itinerary
  • Are you visiting any additional countries?

  • Trip Description - please tick all appropriate boxes:
  • Purpose of Trip:
  • Type of Trip:
  • Accommodation
  • Traveling
  • Location Type
  • Activity Type
  • Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
  • Does having an injection cause you to feel faint?
  • Do you or any close family members have epilepsy?
  • Do you have any history of mental illness including depression or anxiety?
  • Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
  • Have you taken out travel insurance?
  • If you have a medical condition, have you told your insurance company about it?
  • Are you pregnant, planning pregnancy or breast feeding?

  • Vaccine History

    Have you ever had any of the following vaccinations / tablets and if so, when?
  • Should be Empty: